Healthcare Provider Details

I. General information

NPI: 1184602724
Provider Name (Legal Business Name): KIM S. ENDRES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 MEDICAL PKWY STE 430
ANNAPOLIS MD
21401-3263
US

IV. Provider business mailing address

2002 MEDICAL PKWY STE 430
ANNAPOLIS MD
21401-3263
US

V. Phone/Fax

Practice location:
  • Phone: 410-571-2946
  • Fax:
Mailing address:
  • Phone: 410-266-2700
  • Fax: 410-269-1149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: